UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF MISSISSIPPI Plaintiff(s) v. CIVIL ACTION NO. Defendant(s) COMPLAINT 1. This civil action is commenced by , Plaintiff, under thefollowing statutory law (place a check mark in the appropriate box): G Title VII of the Civil Rights Act of 1964, 42 USC 2000e et seq., for employment discrimi- nation on the basis of race, color, sex (gender, pregnancy, and sexual harassment), religion, or national origin. G The Age Discrimination in Employment Act [ADEA], 29 USC 621 et seq. G The Americans With Disabilities Act [ADA], 42 USC 12102 et seq. G The Equal Pay Act [EPA], 29 USC 206(d). G The Rehabilitation Act of 1973, 29 USC 791 et seq. (Applicable to federal employees only). 2. Plaintiffs address is (Street or P.O. Box) (City) (State) (ZIP)3. Defendants address is (Street or P.O. Box) (City) (State) (ZIP)4.A. Plaintiff (check one) G sought employment from the Defendant or, G was employed by Defendant at (City and State) >>>> 24B. If Defendant is an employer G At all times relevant to this claim of discrimination, Defendant had employees. (Insert number) 4C. If Defendant is a union G At all times relevant to this claim of discrimination, Defendant had members. (Insert number) 5A. If the act(s) of discrimination happened on one day only G The discrimination happened on this date: 5B. If the act(s) of discrimination happened on more than one day G The discrimination began on this date: and ended on this date: . 6. On or about Plaintiff filed charges against Defendant with the EqualEmployment Opportunity Commission [EEOC], charging Defendant with the acts of discrimination stated in paragraph 10 of this Complaint. [Not applicable to federal employees]. 7. On or about the EEOC issued Plaintiff a RIGHT TO SUE LETTER.8. Plaintiff received the RIGHT TO SUE LETTER on or about . Notice: Attach to this Complaint a copy of your RIGHT TO SUE LETTER and the envelope in which the letter was received by you. 9. (Check one): The EEOC issued a DETERMINATION: G Yes G No Notice: If you checked Yes, attach to this Complaint a copy of the EEOCs DETERMINATION . -2- >>>> 3 Special Instructions: Please read paragraph 10 carefully and completely before completing. 10. Defendant (place a check mark in all of the following selections that are applicable to your Complaint) G Failed to employ Plaintiff G Fired Plaintiff G Failed to promote Plaintiff G Harassed Plaintiff G Other (specify clearly and briefly): because of G Plaintiffs race (state your race ) G Plaintiffs color (state your color ) G Plaintiffs sex (gender, pregnancy, or sexual harassment) (If applicable, state your sex and your claim: ) G Plaintiffs religion (state your religion ) G Plaintiffs national origin (state your national origin ) G Plaintiffs age (state your date of birth ) G Plaintiffs disability (state your disability ) G Plaintiffs earlier complaint of discrimination or opposition to acts of discrimination. (If you are alleging Retaliation, state the acts or events that you claim constitute retaliation: ) The acts or omissions stated above are:G still being committed or omitted by Defendant; or, -3- >>>> 4 G no longer being committed or omitted by Defendant.11. State specifically and briefly what Defendant, or Defendants agents, or Defendants employees did thatconstitutes discrimination against you personally. Include in your statement specific dates and specificevents or acts, and any specific comments or statements made by Defendant, Defendants agents, orDefendants employees pertaining to your discrimination claim. 12. State the names of witnesses who would testify for you or on your behalf, and state briefly what theywould say. WITNESSS NAME WHAT THIS WITNESS WOULD SAY -4- >>>> 513. Name all documents that you know of which would support your claim and state briefly what eachdocument says or shows. DOCUMENT WHAT THE DOCUMENT SAYS OR SHOWS 14. (If applicable) Plaintiff has attached to this Complaint a copy of the charge Plaintiff filed with theEEOC. This charge is submitted as a brief statement of the facts supporting this Complaint.15. Plaintiff requests that the court grant Plaintiff the following relief: G Defendant be ordered to employ Plaintiff G Defendant be ordered to re-employ Plaintiff G Defendant be ordered to promote Plaintiff G Defendant be ordered to -5->>>> 6 and that the court give Plaintiff such other relief as may be appropriate, including injunctive orders, damages, costs, and attorneys fees. 16. I declare or certify or verify or state under penalty of perjury that the facts and statements in this Complaint are true and correct. Date: Plaintiffs Signature Plaintiffs Printed Name Plaintiffs Street or P.O. Box Address City State ZIP Plaintiffs Telephone Number -6-

Forms provided by US Legal Forms, a third-party service that sells forms for a fee. Justia has no commercial relationship with US Legal Forms, and we receive no commissions, fees, or any other type of compensation if you purchase forms from them.